Christopher Talbot
29 Nov 2017 · Coroner Nicholas Rheinberg · Preston and West Lancashire
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of written training material for reception staff
“The Supervising Officer on duty at Reception when Mr [name redacted] arrived had never received training in her duties but merely gained experience by shadowing another officer. It did not appear that any written material was provided so as to inform her of her duties, including the PSI”
2. absence of breathing guard during resuscitation
“A Senior Officer gave mouth to mouth resuscitation to Mr [name redacted] without the use of a guard. It is understood that although mandatory for more junior officers at HMP Preston, carrying a breathing guard at all times is discretionary for certain senior grades.”
3. lack of awareness of prior death involving plastic bag
“It is understood that following the death of a prisoner a notice to this effect is issued to the prisoners and staff but that staff are not informed of the manner of an unnatural death. Thus, it appeared that staff attending to give evidence at the inquest were unaware of another recent previous death involving a plastic bag”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“(2) A Senior Officer gave mouth to mouth resuscitation to Mr [name redacted] without the use of a guard.”
Later report
“An officer attempting resuscitation carried out mouth to mouth resuscitation without the safeguard of mouth protection which was not available in the prison at the time.”
Responses
No published response was found on judiciary.uk.